Violations of International Code of Breast‐milk Substitutes (BMS) in commercial settings and media in Bangladesh

Abstract The International Code of Marketing of Breast‐milk Substitutes (BMS) instituted to protect breastfeeding against unethical marketing, has been adopted by many countries, including Bangladesh. Despite national adoption, evidence suggests violations occur and inadequate BMS Code implementation is an issue. The study aimed to assess violations of the International BMS Code and the national ‘Breast‐milk Substitutes, Infant Foods, Commercially Manufactured Complementary Foods and the Accessories Thereof (Regulation of Marketing) Act, 2013’ of Bangladesh in commercial settings (retail outlets and media) in Bangladesh, for different types of milk, bottles, and teats using a standardized Network for Global Monitoring and Support for Implementation of the Code and Subsequent relevant World Health Assembly Resolutions (NetCode) protocol. This cross‐sectional quantitative study was conducted in Bangladesh from January to September 2018 in Dhaka, Chattogram, and Sylhet cities. Descriptive statistics were reported and χ 2 tests were conducted to assess differences between categorical variables of interest. Data were analysed using SPSS version 20. In retail outlets, there were higher proportion of violations observed in Dhaka than in Sylhet and Chattogram (p < 0.001). Significantly greater proportion of violations in product labels occurred among products sold without local distributors compared to others (p < 0.05); violations were higher among “other milk” for children aged 0 to <36 months compared to formulas and growing‐up milk (p < 0.05). Among media channels, internet clips had significantly higher proportions of violations compared to television, radio and newspaper (p < 0.001). BMS Code violations were prevalent in product labels and promotion of products through retail outlets. The study findings highlight the need for specific multisectoral strategies for better enforcement of BMS Code and points to the need for periodic assessment of Code violations.


| INTRODUCTION
Globally, it is estimated that optimal breastfeeding practices could help avert 823,000 deaths among under-5 children and 20,000 maternal deaths annually (World Health Organization [WHO], 2021). Breastfeeding in early childhood can potentially prevent several infectious diseases, malnutrition and other noncommunicable diseases later in life (Baird et al., 2017). Despite the known benefits of breastfeeding, globally only 42% and in Bangladesh 65% of mothers exclusively breastfeed their infants for the first 6 months following birth (Gupta et al., 2019;National Institute of Population Research and Training and ICF International, 2019). In Bangladesh, 36% of females are employed, with a large number of them working in the readymade garments manufacturing industry (Haider & Thorley, 2020). As more women join the workforce (Rahman & Islam, 2013), mothers are facing challenges such as inadequate maternity leave, excessive workload, lack of skilled support for breastfeeding at health facilities and community, inadequate and low-quality crèche facilities at work and unfavourable workplace policies (Hasan et al., 2020), which impede breastfeeding.
Moreover, aggressive marketing of breast-milk substitutes (BMS) play an important role in reducing the optimal duration of breastfeeding . Pervasive marketing of BMS have been shown to adversely impact knowledge, intention, beliefs, self-efficacy and social norms related to breastfeeding (Green et al., 2021). COVID-19 pandemic has created an additional threat to optimal breastfeeding, as BMS companies have capitalized on the fear of possible transmission of the infection through breast milk, to promote the use of BMS products (Ching et al., 2021). To counter this threat and maximize survival and health of newborn children globally and in Bangladesh, stakeholders must stay vigilant and act immediately to sustain the progress made at protecting, promoting and supporting breastfeeding.
The International Code of Marketing of BMS (hereinafter referred to as 'the Code') represents the international policy framework to protect breastfeeding against inappropriate and unethical marketing practices from manufacturers and distributors of BMS products (WHO, 1981;WHO & UNICEF, 2003). The Code was adopted by the World Health Assembly (WHA) in 1981 (Holla-Bhar et al., 2015;WHO, 1981) and subsequently adopted by 139 countries in- Family Welfare, 2017). There are some differences between the Code and the Act. For instance, the age of the children included and guidance on violations among product labels and promotion in retail outlet stores (The Government of the People's Republic of Bangladesh, 2013). Where the Code and the Act align are with respect to regulations against inappropriate sales promotion of BMS through contents/messages in product labels, promotional activities in retail outlets, media content, and promotion of BMS at health facilities focusing on health care providers and mothers of young children (Michaud-Létourneau et al., 2019;WHO, 2020). Despite nationwide adoption of BMS regulations, there has been significant challenges in implementation (Michaud-Létourneau et al., 2019) and several violations of the Act were detected through a pilot project in Bangladesh (Bangladesh Breastfeeding Foundation, 2014). In previous studies conducted in Bangladesh, lack of knowledge of the Act and the absence of a strong monitoring and enforcement system were identified as reasons for violation of regulations by manufacturers, distributors and health professionals (WHO, 2020). BMS Code violations in commercial settings such as retail outlets and media are considered crucial and researchers have reported existence of such violations from many countries around the world. In a recent study conducted in Ethiopia, researchers reported that majority of BMS Code violations happened through posters at retail outlets and television (TV) channels and all product labels violated at least one item of the Code (Laillou et al., 2021). A media analyses in Cambodia and Senegal revealed that BMS product advertisements claiming both health and nutritional benefits were frequently aired on local TV channels (Champeny et al., 2019). In Bangladesh, research reporting violations of BMS Code is scarce and have typically focused on health facilities (Taylor, 1998). However, there are a diverse range of marketing channels open to manufacturers and sellers of BMS products outside the health facility . With growing numbers and types of retail outlets and media reach, it has Key messages • This is the first known study documenting violations in retail outlets, online stores, and media using the standard NetCode protocol in Bangladesh.
• BMS Code violations were high in retail stores and were more prevalent in the capital city compared to others.
• Violations were significantly higher in the internet compared to radio, television, and newspapers, highlighting the need for strengthening the monitoring of internetbased promotions.
• It is essential to allocate resources to sensitize retail stores to the BMS Code to enhance the implementation of the law. become necessary to assess the violations of the Code in commercial settings and media in countries that adopted the Code (WHO, 2017b Through the network, specific methodologies were developed for monitoring and periodic assessment of BMS Code violations. Net-Code recommends that periodic assessment is conducted every 3-5 years, to quantify the level of compliance with BMS Code (WHO, 2017a). In Bangladesh, the NetCode methodology has not been employed thus far. Our findings could be used to benchmark BMS Code violations in Bangladesh for future periodic assessments.
The assessment of BMS Code violations will inform the design of targeted intervention to strengthen implementation, monitoring and enforcement of BMS Code in Bangladesh.

| Study design and settings
A cross-sectional quantitative study aimed at assessing compliance with the Code and the Act in commercial settings, retail stores and media was conducted in Bangladesh from January to September 2018. We designed the study on the basis of the retail, label and media modules of NetCode toolkit protocol for periodic assessment (WHO, 2017a). The NetCode toolkit makes provision for monitoring and periodic assessment among key channels and primary respondents: mothers, health facilities, retail stores and media. The current analysis includes data from retail stores and media modules for BMS Code violations (Table 1). BMS products are any food or drink 'being marketed or otherwise represented as a partial or total replacement for breast milk, whether or not suitable for that purpose' and include any milk products, food, bottles and teats (Shubber, 2011). For our current analysis, we restricted our assessment to infant formula (0+ months), follow-up or follow-on formula (6+ months), growing-up milk (12+ months), any other milk for children (0 to <36 months), bottles and teats (WHO, 2017a). We conducted a survey in the retail outlets of three major cities in Bangladesh: Dhaka, Chattogram and Sylhet. Evidence shows that large cities usually encompass the largest market share for any BMS product (Baker, Russ, et al., 2021;WHO, 2017a). Therefore, BMS product range available in shops and pharmacies in smaller cities and rural areas are not likely to exceed the product range available in the large cities. To select the retail outlets, we randomly selected two wards (administrative areas) of Dhaka and purposively selected one ward from each of Chattogram and Sylhet for the survey. For the media component of the study, a media firm conducted a retrospective scan of advertisements from all major local mass media channels (newspaper, radio and television) for a period of 6 months (January to June 2018) and data from the internet were collected prospectively for 2 months (August and September 2018), to capture the marketing and promotion of selected BMS products in Bangladesh. Promotions of BMS in the media are activities or dissemination of information for marketing, sales or distribution of the BMS products through media channels.
The promotions could be through advertisement, information note, interview, information broadcasted through news reporting in TV/ radio or newspaper, or internet (news report), viral internet marketing for specific product or brand, incentives for product promotion, sweepstakes, club membership, opinion, analysis, debate and others.

| The Code and the Act
We considered provisions from both the Code and the Act. There are differences between the two: the Code includes provision for children up to 36 months of age (WHO, 2017a), whereas the Act expanded the scope of restrictions to 0-5-year-old children (The Government of the People's Republic of Bangladesh, 2013; WHO, 2020). For product labels, the Act has a few requirements in addition to those described in the Code (Appendix A3). For product labels, the additional requirements for the Act were as follows: display of registration number from relevant authority in Bangladesh, size of the company logo should not be more than half of the size of the product name, must use words suitable or usable for a 'child' or other similar words, must use picture of baby or mother, or both, and have graphics or cartoon for easy identification of BMS. The Act prohibits any display of the BMS products in retail outlets (The Government of the People's Republic of Bangladesh, 2013). Therefore, this assessment reported a category named 'any display', which included those that do not fall within the scope of brand shelf, special display, shop window, poster, banners, shelf-tags, talkers and product launch. For review of promotional materials collected from retail outlets, we added additional criteria related to the Act such as type of promotion found in the information notes (education information), price-related promotions and free gifts, whether the promotional material contains information on the following: benefits of colostrum, initiation of breastfeeding within 1 h of birth, exclusive breastfeeding for 6 months, feeding homemade food in addition to breast milk after 6 months, importance of breastfeeding up to 2 years of age and information on appropriate way of breastfeeding and continuation thereof (The Government of the People's Republic of Bangladesh, 2013; WHO, 2020). In this study, we will report findings according to the Code, to enable transnational comparison and, whenever appropriate, we will include discussions about the Act.

| Sample selection
To assess the labels of BMS products at retail outlets, we selected five large stores randomly through lottery from all the large stores mapped in Dhaka city as per NetCode methodology. Large stores were considered those selling a high volume and variety of BMS products (chain grocery stores, supermarkets, baby stores and chain pharmacies; Table 2). When one store refused (only occurred for two stores) to participate, it was replaced with another randomly selected store from the list. For assessment of the labels, we started in one large store, purchased a single item of every relevant product and took them to the central office to create a list and assess the product labels. All products found at the second store (not appearing on the existing list) was purchased and, accordingly, the list was updated.
Similar procedure was followed for all five large stores until no new products were found. From large stores in Chattogram and Sylhet, we added a few additional BMS products that met the study criteria to our list for assessing product labels.
To assess in-store promotion of BMS products, a two-step process was performed to sample three types (large, small and online) of retail generator from the list of stores obtained through mapping. Data collected from a total of 129 stores in Dhaka, Sylhet, and Chattogram, were assessed for in-store promotions (Table 2). For online stores, a list was made by searching the web and on the basis of local knowledge on online retailers that sell products within the scope of our study. We selected five online stores randomly from 18 online stores identified from web search. For the media assessment, we identified six major TV channels, five radio stations and eight daily newspapers (seven Bangla and one English) based on their popularity and reach.

| Data collection
For data collection at retail outlets, data collectors obtained permission from the store managers to take photos and conduct observation. All the unique products were purchased, photographed and given an identification number. The data from the labels were then summarized using a digital form that included company name and brand, product name, package size, recommended ages, product type, language used and criteria for both the Code and the Act. For the media scan, data on snapshots of newspaper, internet clips, audio and video clips were collected for review after removing duplicates and ensuring that they met the selection criteria. The data on the unique media clip was summarized with a prescribed form.
The form recorded details on the type of promotion, source of promotion, brand, company, messages conveyed and type of products.
All data collected were entered using online formats to reduce entry error.

| Data analysis
Data on product labels and promotional materials (including pictures and samples) from the retail outlets were reviewed and described using a separate prescribed form. Product labels data were analysed by using a predeveloped checklist that listed Code-noncompliant answers to define 'violation'. Additional criteria for the Act was added 3 | RESULTS

| BMS Code violations in retail outlets
We identified a total of 106 unique BMS products of which 67 (63%) were milk products and the rest were bottles and teats. In Sylhet cities, small stores such as corner stores, pharmacies and groceries were more likely to use display promotion for BMS products compared to the larger stores, although the difference was not statistically significant. However, in Chattogram city we observed that larger stores tend to have more promotions than the small stores, although the difference was not statistically significant ( Figure 3).

| BMS Code-violations in media
There were 243 unique clips identified during media scan that met our assessment criteria. Most of the unique clips were from internet (n = 154), followed by newspaper (n = 39), TV (n = 34) and radio (n = 16; Table 3). Advertisement was the most common promotion observed, followed by news reports and incentives for product purchase. In 31 clips, breastfeeding was promoted, which was observed on Mother's online forums only. In TV, radio and newspaper advertisements, violations were observed for 'any other milk' for children only (Table 3). We observed advertisements on significantly more types of BMS products on the internet compared to other media sources (p < 0.001) ( Table 3). To advertise milk-based BMS products, the claims were made about the product being nutritious, healthy and touting its contribution to child growth and building immunity. The feeding bottles were mostly advertised as convenient and healthy. The teats were advertised by focusing on its healthy composition, convenience of use and its similarity to mother's breast.

| DISCUSSION
The findings of the current study reveal considerably high-levels of violations of BMS Code in the commercial settings of retail outlets and in the media, especially the internet, in Bangladesh. In terms of promotion of BMS in retail outlets, proportion and type of violations differed by city. Product label violations were universal and higher in products that did not have local company involved in distribution. The traditional media such as radio, TV and newspaper were quite compliant to BMS Code. However, a wide range of BMS products were promoted through social media and webpages. Although violations of BMS Code has been reported from Bangladesh previously (Joshi et al., 2014;Rahman & Akter, 2019;Taylor, 1998), this is the first study documenting violations in retail stores, online stores and media using the standard NetCode protocol (WHO, 2017a).
We found that all the labels of BMS products violated at least one aspect of both the Act and the Code. In studies conducted in Turkey, Cambodia and Mexico comparably high levels of the Code violation in product labels were reported by researchers (Ergin et al., 2013;Hernández-Cordero et al., 2019;Hou et al., 2019). The level of violations in product label calls for serious attention to the existing policy and monitoring mechanism around BMS Code violation. Further, market leaders among BMS companies should be engaged to find a way to improve compliance to the Code. We found that BMS products associated with local companies were more likely to comply with BMS Code compared to products that are not directly linked to local companies. This is probably because local companies are more aware of the Act and, therefore, tried to comply with the local regulations. However, quite a number of BMS products were sourced without linkage to local companies.
Despite existing rules about BMS import, it is crucial to understand how to adequately monitor the channels of BMS import so that compliance to the Act can be ensured. It is also important to understand the existing mechanism that monitor the retail stores so that products that do not comply with the BMS Code and Act are not sold to the consumers.
We  Teats 29 a More than one type of product was promoted through multiple clips.
to evaluate the feasibility of such a provision for retail outlets.
Whether such stringent regulations are feasible in the context of Bangladesh and setting more realistic expectations on the display of BMS products in retail stores is a matter worth revisiting by policymakers.
In the media outlets, we found very few advertisements of BMS products, which shows that there have been efforts to comply with BMS Code in the major mainstay media channels such as television, radio and newspaper. The few advertisements for milk products observed were of 'other milk', which were not specifically labelled for any specific age group, particularly for infants or young children. Nevertheless, these products were advertised as 'nutritious', 'healthy', and 'good for growth and development of the children', implying that the products might be consumed by young children. Similar findings from media audit reported inappropriate promotion of milk products (not just other milk) in other countries of Southeast Asia (Vinje et al., 2017). One important issue to consider is that the Act includes under-5 children and 'other milk' is an important source of nutrition for young children. Therefore, for the Act it is important to come up with guidance about 'other milk' that protects breastfeeding but promotes the use of milk for older children. We found most media promotions of BMS products were conducted through internet. It is important that newer media channels such as internet are monitored by relevant government authority for BMS Code violations and necessary steps taken to strengthen enforcement.
In Bangladesh, the rates of exclusive breastfeeding have stagnated in recent years (Hossain et al., 2018;Rahman et al., 2020) and use of BMS products have risen (Rollins et al., 2016). In this situa- Our study had a number of limitations. We only looked at milk products, bottles and teats while there are other categories of BMS products (e.g., complementary foods), which are being sold but were not considered due to resource constraint. It must be noted that there are several companies that use marketing strategies to promote BMS products as complementary foods (Berry et al., 2010). We assessed stores located in three major city corporations of Bangladesh and, therefore, our findings may not be applicable for smaller cities or rural areas. For media analysis, we considered local media sources but did not include international TV channels that are pervasive. The analyses of internet marketing were limited to a few publicly available sites and pages, whereas there may be other social media pages or sites that allow moderator-regulated or consumer-targeted access that we missed out.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

ETHICS STATEMENT
Local ethical clearance was obtained from the Ethical Review Committee of icddr,b before conducting the survey of retail outlets (icddrb protocol #: PR-18022